02 September 2008

So I am seeing this elderly man for syncope. He came in via EMS, having keeled over and fainted at the dinner table with his wife; fortunately, he woke up fairly briskly. As it had happened, I was hanging out in the nurses' station when the EMS phone rang, so I answered it, and took the report from the medics. It sounded fairly routine, and a few minutes later when they came rolling in to their assigned room I was there to greet them. (We were not real busy, for once.)

The medic was one I did not know. We have tremendously good medics and I have come to trust and rely on them over the years, so although this was a new face to me, I took him at face value when he told me that there was nothing out of the ordinary to report: just another old fella who fainted, normal vitals, looked fine, no clear cause. For his part, the patient was sitting up in the gurney, smiling and taking in the sights.

The medics finished offloading and took off. I interviewed and examined the patient, and ordered a whole slew of tests. The story was a little concerning, since when someone (especially an older person) faints without a clear cause (fever, dehydration, using the toilet, getting up too quickly), you worry about cardiogenic syncope -- that the heart had abruptly stopped effectively pumping blood, most often due to an aberrant rhythm, either too fast or too slow. This can be tricky to sleuth out, though, because it's just like when you have an intermittent electrical problem with your car -- when you take it to the dealer, they can't reproduce the problem, and thus can't figure out what needs to be fixed. Similarly, when someone gets to me with suspected cardiac syncope, they are usually back in a normal heart rhythm and thus I can't tell what happened. So they generally get admitted for tests and observation, but it's frustrating because frequently we are unable to sort out the ultimate cause of the event.

So it was here. His ECG was normal for me, and his tests were all fine, so I planned on admitting him to the hospital team. I pulled the chart off the rack and began going through all the papers to make sure I had everything I was going to need. As I did, a sheaf of papers, including the ambulance report and about a dozen ECGs from the ambulance fell out. The local EMS uses these cardiac monitors which spew out tracing after tracing, on their own, whenever the machine sees fit. I flipped through them, and the first few were fine, but the fourth one stopped me short. it looked exactly like this:It was the most obvious ventricular tachycardia I had ever seen, and appeared to have lasted about thirty seconds. Damn, well that explains that! One mystery solved and I've got a diagnosis. But why the hell had the medic not seen fit to mention it to me? I mean, sheesh, for most medics that would have been one of their most exciting runs of the day, and they'd be bugging me to push lidocaine and putting on the defibrillator patches and all that good stuff. Yet this medic had been exceptionally blase about the whole thing. Had he even noticed it? I referred to the report. Yup, right there he wrote down "V-tach" as the rhythm. Unbelievable.

A bit later, the same crew came in with another patient. I discreetly took the medic aside and asked why in heaven's name he had not bothered to mention the V-tach. He gave me the same look my three-year-old gives me when I ask him why he's not wearing underwear and weakly replied, "Oh yeah, I forgot about that."

What can you possibly say to that? I'm not a vindictive guy, but after some, shall we say "emphatic counseling," I made sure to send a note to the medical director that this individual might bear a little extra supervision or education.

And let that be a cautionary tale to all the ER docs out there: always review the paramedics' and nurses' notes. You'll never know what's in there unless you look.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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